By JUDITH EVANS
CHRISTUS HEALTH
In San Antonio, doctors, nurses, social workers and law enforcement officers are working together to identify children who are victims of abuse — and just as importantly, to identify injured children who are not.
"There are a lot of instances where a child will come in with an injury, and people along the line will have jumped to conclusions and say there is abuse," said Dr. James Lukefahr, a board-certified child abuse pediatrician and medical director of the Center for Miracles, a joint venture of the CHRISTUS Santa Rosa Health System, Children's Hospital of San Antonio (which is part of CHRISTUS Santa Rosa) and the University of Texas Health Science Center at San Antonio.
Perhaps a child comes to the emergency room with a fracture that the parents report had happened on the playground. Emergency room doctors might suspect abuse, triggering a review by the Center for Miracles. "That's a very common scenario," Lukefahr said. "ER docs are not experts in child abuse. They might interpret an injury one way, erring on the side of caution. We want them to do that. We want to have a few cases over-interpreted, and we straighten them out."
He said about one in four cases brought to the attention of the center turn out not to be abuse. Those children and their families are spared the trauma of legal proceedings and perhaps foster care.
But the remainder of the time, abuse allegations prove to be true. The children might have been physically or sexually abused, or they might have been neglected and are failing to thrive. "We've had some really dramatic instances when children have presented to the hospital in a severely undernourished, starved state," Lukefahr said. "We've been able to show that the child actually hasn't been fed, and get the child to a safe situation quickly."
Expert witnesses
Since the Center for Miracles opened in May 2006, doctors have seen more than 9,000 children or assessed their medical records, said Tim Reznicek, clinic coordinator and one of the center's two social workers. Some children are examined in the clinic and some during hospital stays, he said. In addition to Lukefahr, the center is staffed by Dr. Nancy Kellogg, a pediatrician who specializes in sexual abuse, and Dr. Sandeep Narang, a pediatrician and attorney. Kellogg is one of only 264 pediatricians in the U.S. and Canada to be board-certified in the subspecialty of child abuse since the American Board of Pediatrics started administering that board exam in 2009.
All three doctors are faculty members in the University of Texas' medical school's Division of Child Abuse Pediatrics. Narang supervises the center's three fellows, who are pediatricians training to become child abuse specialists. As an attorney, Narang also helps the fellows prepare when they are called to testify in court, and he meets regularly with the police department. "He's a real asset to our clinic," Reznicek said.
The center also has a pediatric nurse-practitioner who focuses on child neglect and development issues, such as failure to thrive, and a nurse trained to conduct medical exams of suspected victims of sexual abuse.
The University of Texas provides the Center for Miracles with doctors and nurses, and Children's Hospital of San Antonio provides the support staff and social workers. CHRISTUS helps pay for the facility and administrative costs, and the state of Texas provides additional funding, Reznicek said.
"Our purpose is to provide timely, accurate and comprehensive medical assessment of children who are suspected victims of abuse or neglect," he said.
Justice served
The Center for Miracles was conceived after the San Antonio area grappled with a spate of fatal child abuse cases, Reznicek said. The San Antonio-based Kronkosky Charitable Foundation funded a feasibility study to determine what could be done. "Two social workers were commissioned," Reznicek said. "They determined we were missing the medical component in the child-abuse cases."
At the time, Reznicek worked for Child Protective Services. He said that caseworkers had trouble getting timely, accurate, in-depth information from the emergency rooms, clinics and primary care doctors who treated abuse victims. Because those medical professionals were not trained in spotting child abuse, they sometimes weren't running the necessary tests or ordering the X-rays that could help prove or disprove allegations. "Unless somebody might have the time, skill and expertise in that area, something might be missed," he said.
Based on the feasibility study, the Goldsbury Foundation, a private, family-based foundation in San Antonio, awarded $1.2 million to open the doors of the Center for Miracles.
In addition to providing complete medical assessments of children suspected of being victims of abuse and assessments of their siblings, the Center for Miracles provides consultations with doctors at hospitals; photo documentation of injuries; expert court testimony; and therapy, conducted at no cost to the families by two Ph.D. students from San Antonio's Our Lady of the Lake University, Reznicek said. The center also refers patients to therapists in other locations. "Counseling is an extra role that we provide, and a very important role, but it's only a small piece of what we do," he said. "Some of the families are very comfortable coming to our clinic. Others prefer to go closer to their home. We give them various options."
Lukefahr said that children who have been sexually abused are referred for counseling to San Antonio's ChildSafe, a companion agency.
Most of the victims of physical abuse and neglect are under age 3, and one-third of them are younger than 2. Referrals come from a variety of sources, including Child Protective Services, law enforcement officers, schools, and pediatric offices and clinics, Reznicek said.
Lukefahr said doctors talk at length to parents, grandparents or others who care for the babies. "If a child is old enough to give us their history directly, we put most of the weight on that," he said.
The doctors also make regular visits to Child Protective Services and the San Antonio Police Department to review cases and provide information, Reznicek said. "We're all working on these cases, but we all have a different role," he said. "It helps us understand what our role is and how we can work together."
Mutual support
Lukefahr and Reznicek agreed that having a strong support system helps them cope with the sad situations that they see daily. "It's a difficult field to be in," Reznicek said. "In our clinic, especially, we're seeing very serious cases every day. You have to get support from each other, your family, friends, your faith, and just realize that ultimately we're here to help children."
"We're very blessed to have the support of our staff and each other," Lukefahr said. "Some days are really rough, but other days, we can pick up the phone and make a really big difference in a child's life, and those are the days we live for."